Patient Medical History Form (Adult)

ADVERTISEMENT

PATIENT MEDICAL HISTORY
ADULT
C0390-0085
DATE ________________
1.) SOCIAL HISTORY
Name ____________________________________________________________________________ Birthdate ____________________________
/
/
(Last)
(First)
(M.I.)
(Month)
(Day)
(Year)
Occupation ____________________________________________________________ Education (# of Years Completed) __________________
Marital Status __________
Spouse’s Name ______________________________________________
Religion ____________________________
Special cultural beliefs that might affect your healthcare ____________________________________________________________________________
K
K
K
K
Do you have a Power of Attorney for Healthcare?
Yes
No
Do you have a living will?
Yes
No
K
K
Use of home health or other community services?
Yes
No
Name of Health Care Providers ________________________________________________________________________________________________________
2.) PAST MEDICAL HISTORY
Have you ever had (if so, when): __________________________________________________________
K
K
K
K
Alcoholism
Coronary heart disease
Hemorrhoids
Pleurisy
K
K
K
K
Aids / related complex
Diabetes
Herpes
Pneumonia
K
K
K
K
Anemia
Diphtheria
High cholesterol / lipid levels
Rheumatic fever
K
K
K
K
Asthma
Emotional problems
High / Low blood pressure
Sexually transmitted disease
K
K
K
K
Bone / joint problems
Epilepsy / seizures
Jaundice
Stomach disease
K
K
K
K
Cancer; type: __________________
Gallbladder
Kidney disease
Stroke / paralysis
K
K
K
Gonorrhea
Liver disease / hepatitis
Thyroid disease
K
K
Migraines
Tuberculosis
Other: ____________________
3.) HOSPITALIZATIONS
K
K
Have you been hospitalized for any other problems?
Yes
No (If so, please list) ________________________
__________________________________________________________________________________________________________________________________
K
K
K
Have you had:
Appendectomy
Tonsillectomy (age _____ )
Cholecystectomy (Gallbladder)
K
Other surgeries: ______________________________________________________________________________________________________
4.) FAMILY HISTORY
Has any blood relative ever had: (Check all that apply)
K
K
K
K
Alcoholism/Substance Abuse
Cancer; type ______________
High cholesterol
Osteoporosis
K
K
K
K
Alzheimer’s disease
Diabetes
Kidney disease
Senility
K
K
K
K
Anemia
Heart disease
Memory loss
Stroke
K
K
K
K
Asthma
High blood pressure
Mental illness
Tuberculosis; when __________________
K
K
K
Bleeding problem
Thyroid disease
Other ______________________________
5.) MEDICINES
Also include any over-the-counter medications such as vitamins, antihistamines, Tylenol, herbal remedies, etc.
______________________________________________________________________
____________________________________________________________________
______________________________________________________________________
____________________________________________________________________
______________________________________________________________________
____________________________________________________________________
______________________________________________________________________
____________________________________________________________________
6.) ALLERGIES
Please check items to which you are allergic:
K
Drug allergies: (specify) ______________________________________________________________________________________________________________________
K
Food/environmental allergies (specify) ________________________________________________________________________________________________
K
K
K
K
K
Iodine - Shellfish
Bee stings / Insect bites
X-ray / Arteriogram or dyes
Adhesive tape
Latex
K
Other allergies: (specify) ____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
7.) IMMUNIZATIONS
Check those that you have had. (Please note the most recent year received.)
K
K
K
K
Usual childhood immunizations ____________
Flu __________
Pneumonia __________
Tetanus ____________
K
K
K
Chicken pox ____________
Hepatitis __________
Others __________________________________________________________________________
C0390-10000-08-0085-MR (Rev. 1/11)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medical History Form - Adult Missions Ministry Team Medical History Form - Adult Missions Ministry Team Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2